Child Enrollment Form

Here you will find the forms needed in order to sign your child up for AiN. If you have a child with special needs and would like to apply for our program, please fill out the annual enrollment form and submit it.

Please also submit a copy of the doctor’s note or a current copy of the IEP, or other forms showing child’s eligibility. Once we receive your enrollment form, we will set up a phone interview with the family. We will invite you to come to a Revive or Social Club event so you can view the program and we can meet the child.

Medical/ Health Considerations

Please specify medication dosages and required times for administration:
*

Child's Method of Communication

Does your child communicate using any of the following?

Speech

Sign Language

Non-verbal

Uses communication devices or picture board

OtherOther

Check all that apply

Please elaborate. Can child make his/her needs known?

Child's Education Skills

Can your child?

Read

Write

Follow 2 - 3 step directions

Remember and follow established routines/processes

Stay on task

Check all that apply

What are the approximate grade levels for each of the above skills?

Parent's Information

Do both parents live with the child?

Yes

No

Mother's Full Name

Address (if different than Child's)

Home Phone

Mobile Phone

Email Address

Father's Full Name

Father's Address (if different than Mother's)

Home Phone

Mobile Phone

Father's Email Address

Do you need additional care for siblings - ages 3 through 5th grade?

Yes

No

Names and ages

In Case of Emergency

Emergency Contact (other than parents)

Relationship to Child

Address

Home Phone

Mobile Phone

Secondary Emergency Contact

Relationship to Child

Address

Home Phone

Mobile Phone

Name of Hospital/Clinic Preference

Hospital/Clinic Phone Number

Do you have a do-not-resusitate (DNR) order for this child?
*

Yes

No

Please submit a copy of the order to the office so we can respond appropriately in an emergency.

Digital Signature

I authorize all medical and surgical treatment, x-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent.
*

Full Name

Date

I release All in Need, Family Support and individuals from liability in case of accident during activities related to All in Need, Family Support as long as normal safety procedures have been taken.
*